Understanding trends and variation in paediatric fracture management in England

One hospital in Ireland calculated a paediatric fracture incidence rate of approximately 29 fractures/1,000/year¹. The most common fracture was distal radial/buckle fractures (27.2%), followed by distal humerus /supracondylar fracture (13.9%), ankle fractures (9.2%), phalanx fractures (8.3%), and radial/ulnar metaphysis fractures (5.7%). It is suggested the incidence rate will depend on the social emphasis on encouraging physical activity¹.

Between 2012–2019, 368,120 children under 18 were admitted to English NHS hospitals with a fracture; 256,008 (69.5%) were upper limb and 85,737 (23.3%) were lower limb fractures². The annual incidence of upper limb fractures was highest in children aged 5–9 (348.3 per 100 000 children).

British Society for Children’s Orthopaedic Surgery (BSCOS) guidance suggests that no referral/follow up is required for many fractures of the clavicle, elbow, wrist and toes where there is no or minimal displacement³.

The FORCE study found in children with a torus fracture of the distal radius there was no difference in outcomes between those who were offered of a bandage and immediate discharge (as per UK National Institute for Health and Clinical Excellence recommendations) and those receiving current treatment of rigid immobilisation and follow-up⁴.

One study in Scotland found that uncomplicated paediatric clavicle fractures can be managed without x-rays in the ED as they do not influence ultimate management or add valuable information to clinicians’ assessment⁵.

A GIRFT report on Paediatric Trauma and Orthopaedic Surgery found that over 250 weeks of operating time a year had been dedicated to manipulation of the forearm and wrist between 2016 and 2019¹. A significant proportion of these displaced or angulated wrist fractures could have been manipulated and cast in the emergency department rather than being admitted and treated in the operating theatre. The GIRFT report found significant variation between trusts in the number of manipulating being performed in theatre; if this number was reduced to the level in trusts with well-developed ED manipulation protocols, there would be an 80% (equivalent this number could be reduced by 80% (to 57 weeks or less).

Due to pressures on hospitals from the COVID-19 pandemic the British Orthopaedic Association developed guidelines for the early management of distal forearm fractures in children. A study conducted at one trust found following the implementation of these guidelines resulted in 86% of distal forearm fractures in children were manipulated in the ED, an increase from 32% prior to the COVID pandemic². This saved approximately 63 hours of theatre time in the six-month study period.

The GIRFT report highlighted reluctance to perform procedures in the emergency department because of worries about breach times, a lack of space/facilities to perform sedation and a lack of familiarity with techniques¹.